At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?
Constipation
Indigestion
Swollen ankles
Urinary frequency
None
None
The Correct Answer is B
A. Constipation: While constipation can be uncomfortable, it is not typically considered an immediate threat to a patient's health in a cardiac unit setting. It requires assessment and intervention but is not the highest priority.
B. Indigestion can be a subtle symptom of myocardial infarction (MI) or acute coronary syndrome (ACS), particularly in older adults, women, or clients with diabetes. Clients experiencing "indigestion" may be describing chest discomfort, which requires immediate assessment to rule out a cardiac event. Early identification and intervention for cardiac symptoms are critical to prevent further complications.
C. Swollen ankles can indicate fluid retention, which is a common sign of heart failure. While this symptom requires attention, it does not typically indicate an immediate life-threatening issue compared to potential cardiac ischemia associated with "indigestion."
D. Urinary frequency: This could be related to medications or other conditions. While it should be addressed, it is not the most critical issue compared to potential acute cardiac symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Brushing teeth immediately after eating may exacerbate nausea in some individuals. It is recommended to wait a while after eating before brushing teeth, or rinse the mouth with water.
B. Lying down after meals can worsen symptoms of nausea and reflux. Remaining upright or sitting up after meals may help alleviate symptoms.
C. Drinking large amounts of water with meals may exacerbate feelings of fullness and contribute to nausea. Sipping small amounts of fluids between meals is recommended.
D. Eating a dry carbohydrate, such as crackers or toast, before getting out of bed can help alleviate morning sickness by stabilizing blood sugar levels and absorbing stomach acid.
Correct Answer is B
Explanation
A. While it's important for the client to empty their bladder before surgery to reduce the risk of complications, administering a preoperative injection typically requires monitoring the client closely for any adverse reactions rather than immediately taking them to the bathroom.
B. Asking the client to verify the surgical site helps prevent wrong-site surgery and ensures proper patient safety protocols are followed.
C. Reviewing deep breathing and coughing exercises is an important preoperative teaching, but it's not typically done immediately after administering a preoperative injection.
D. Raising the side rails on the bed is a safety measure to prevent falls, but it's not directly related to administering a preoperative injection.
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